Effects of global and domestic tobacco control policies on cigarette consumption per capita: an evaluation using monthly data in China.

INTRODUCTION: China consumes 44% of the world's cigarettes. Robust tobacco control measures are needed to contain the trend of increasing cigarette consumption. This paper examines the effectiveness of policy interventions introduced in China on reducing the country's tobacco use. METHODS: The paper uses data on China's monthly cigarette consumption per capita from January 2000 to June 2017 to estimate the impact of specific policies on China's tobacco consumption. Tobacco consumption is calculated from monthly sales data from the China National Tobacco Corporation and demographic data from the China National Bureau of Statistics. The policies studied include the WHO Framework Convention on Tobacco Control (FCTC), national tobacco-related policy changes and two tobacco tax increases implemented in China during the study period. Segmented regression analysis is used to estimate the immediate effects of the policies studied and changes in the time trends resulted from these policy changes. FINDINGS: The impact of national policy changes in China is almost 20 times greater than the impact of the WHO FCTC treaty itself, and national policy changes in tobacco control are a determining factor in reversing the trend of increasing tobacco consumption in China. The 2015 tax increase, which raised retail cigarette prices, produced both immediate and trend effects, with a total incremental effect 7.8 times that of the 2009 tax increase, which did not result in higher cigarette prices for the consumer. INTERPRETATIONS: Translating global tobacco control policies into domestic policies will generate a much greater impact on reducing average cigarette consumption, and tobacco taxes that are reflected in the retail prices of cigarettes will be more effective in reducing cigarette consumption.

Economic Burden for Lung Cancer Survivors in Urban China.

BACKGROUND: With the rapid increase in the incidence and mortality of lung cancer, a growing number of lung cancer patients and their families are faced with a tremendous economic burden because of the high cost of treatment in China. This study was conducted to estimate the economic burden and patient responsibility of lung cancer patients and the impact of this burden on family income. METHODS: This study uses data from a retrospective questionnaire survey conducted in 10 communities in urban China and includes 195 surviving lung cancer patients diagnosed over the previous five years. The calculation of direct economic burden included both direct medical and direct nonmedical costs. Indirect costs were calculated using the human capital approach, which measures the productivity lost for both patients and family caregivers. The price index was applied for the cost calculation. RESULTS: The average economic burden from lung cancer was $43,336 per patient, of which the direct cost per capita was $42,540 (98.16%) and the indirect cost per capita was $795 (1.84%). Of the total direct medical costs, 35.66% was paid by the insurer and 9.84% was not covered by insurance. The economic burden for diagnosed lung cancer patients in the first year following diagnosis was $30,277 per capita, which accounted for 171% of the household annual income, a percentage that fell to 107% after subtracting the compensation from medical insurance. CONCLUSIONS: The economic burden for lung cancer patients is substantial in the urban areas of China, and an effective control strategy to lower the cost is urgently needed.

China has raised the tax on cigarettes: what's next?

The Chinese government raised tobacco tax on 10th May 2015, 10 years after the ratification of the WHO Framework Convention on tobacco control. The increase in the resulting tax rate as a percentage of the retail price from 49% to 56% is still relatively low compared to the WHO-recommended benchmark, which is about 70% of the retail price. Therefore, ample room remains for the Chinese government to further increase the tax on cigarettes.

A Clustered Randomized Controlled Trial to Reduce Secondhand Smoke Exposure Among Nonsmoking Pregnant Women in Sichuan Province, China.

INTRODUCTION: Nonsmoking pregnant women in China have significant exposure to secondhand smoke (SHS). Few interventions have focused on pregnant women reducing their SHS exposure. METHODS: This clustered randomized controlled trial, conducted at eight hospitals in Sichuan, China, compared a prenatal health education intervention with usual clinical care as a control. The primary outcome was self-reported "no SHS exposure" before and 3 months after birth. The intervention consisted of three large group educational sessions, standardized clinician advice, brief monthly follow-up calls, and educational materials and resources. A random sample of participants was biochemically validated before birth with hair nicotine, a long-term biomarker of smoke exposure. RESULTS: Overall, 1181 participants were randomized to intervention (n = 526) and control (n = 655) groups. More participants in the intervention group than the control group reported no SHS exposure 3 months after birth (Total: 77.9% vs. 52.6%, P < .001; Home: 81.2% vs. 53.3%, P < .001). The intervention group also had greater changes in improved smoke-free homes and SHS knowledge and attitudes. Controlling for covariates, the intervention group was less likely to report SHS exposure than the control group (Total: OR = 0.47, 95% CI = 0.31 to 0.71; Home: OR = 0.33, 95% CI = 0.21 to 0.53), and this effect was sustained 3 months after birth. The adjusted log concentration of hair nicotine for the intervention group decreased by 0.28 log µg/g more than the control group. CONCLUSIONS: Our smoke-free health education intervention for nonsmoking pregnant women significantly reduced SHS exposure before and after birth. This intervention model can become part of a standard protocol for the care of pregnant women in hospital settings.

The heterogeneous effects of cigarette prices on brand choice in China: implications for tobacco control policy.

BACKGROUND: China has long kept its tobacco taxes below international standards. The Chinese government has cited two rationales against raising tobacco tax, namely, the unfair burden it places on low-income smokers and the ability of consumers to switch to cheaper brands. OBJECTIVE: This study examines how different socioeconomic subgroups of Chinese smokers switch brands in response to cigarette price changes. METHODS: We model smokers' choice of cigarette tier as a function of tier-specific prices. We examine heterogeneous responses to prices by estimating mixed logit models for different income and education subgroups that allow for random variation in smokers' preferences. We use data from three waves of the longitudinal International Tobacco Control China Survey, collected in six large Chinese cities between 2006 and 2009. FINDINGS: Low-income and less educated smokers are considerably more likely to switch tiers (including both up-trading and down-trading) than are their high-socioeconomic status (SES) counterparts. For those in the second-to-lowest tier, a ¥1 ($0.16, or roughly 25%) rise in prices increases the likelihood of switching tiers by 5.6% points for low-income smokers and 7.2% points for less educated smokers, compared to 1.6% and 3.0% points for the corresponding high-SES groups. Low-income and less educated groups are also more likely to trade down compared to their high-SES counterparts. CONCLUSIONS: Only a small percentage of low-income and less educated Chinese smokers switched to cheaper brands in response to price increases. Hence, the concern of the Chinese government that a cigarette tax increase will lead to large-scale brand switching is not supported by this study.

The healthcare costs of secondhand smoke exposure in rural China.

OBJECTIVE: The goal of this study was to assess the healthcare costs attributable to secondhand smoke (SHS) exposure among non-smoking adults (age ≥ 19) in rural China. METHODS: We analysed data from the 2011 National Rural Household Survey which was conducted among adults in five provinces and one municipality in China (N=12,397). Respondents reported their smoking status, health conditions and healthcare expenditures. Relative risks were obtained from published sources. Healthcare costs included annual outpatient and inpatient hospitalisation expenditures for five SHS-related diseases: asthma, breast cancer (female only), heart disease, lung cancer and tuberculosis. SHS-attributable healthcare costs were estimated using a prevalence-based annual cost approach. FINDINGS: The total healthcare costs of SHS exposure in rural China amounted to $1.2 billion in 2011, including $559 million for outpatient visits and $612.4 million for inpatient hospitalisations. The healthcare costs for women and men were $877.1 million and $294.3 million, respectively. Heart disease was the most costly condition for both women ($701.7 million) and men ($180.6 million). The total healthcare costs of SHS exposure in rural China accounted to 0.3% of China's national healthcare expenditures in 2011. Over one-fifth of the total healthcare costs of SHS exposure in rural China were paid by health insurance. The out-of-pocket expenditures per person accounted for almost half (47%) of their daily income. CONCLUSIONS: The adverse health effects of SHS exposure result in a large economic burden in China. Tobacco control policies that reduce SHS exposure could have an impact on reducing healthcare costs in China.

Tobacco control and tobacco farming in African countries.

During the past decade, tobacco leaf production has shifted from high-income countries to developing countries, particularly those in Africa. Most African governments promote tobacco farming as a way to alleviate poverty. The economic benefit of tobacco farming has been used by the tobacco industry to block tobacco control policies. The tobacco industry is active in promoting the alleged positive aspects of tobacco farming and in 'protecting' farmers from what they portray as unfair tobacco control regulations that reduce demand. Tobacco farming has many negative consequences for the health and well-being of farmers, as well as for the environment and the long-term well-being of the countries concerned. We provide an overview of tobacco farming issues in Africa. Encompassing multi-dimensional issues of economic development, there is far more to it than tobacco control questions.

The impact of smoke-free legislation on reducing exposure to secondhand smoke: differences across gender and socioeconomic groups.

BACKGROUND: On 11 January 2009, Taiwan expanded its smoke-free legislation to all indoor public places and workplaces. This study examined the impact of this policy on secondhand smoke (SHS) exposure in adult non-smokers, across gender and socioeconomic status groups (SES). METHODS: An annual sample of about 13,000-14,000 non-smokers was drawn from cross-sectional nationwide data of Taiwan Adult Tobacco Behavior Surveys during 2005-2011. Logistic regressions were used to analyse the aggregate data to estimate the association between the 2009 smoke-free legislation and SHS exposures in homes and workplaces. Interaction terms were used to examine the impact of the 2009 smoke-free policy on reducing differences in SHS exposure across gender, education and income groups. RESULTS: The 2009 policy reduced the odds of SHS exposure in homes in 2009 (OR=0.76, 95% CI 0.68 to 0.84) and in workplaces (year 2009: OR=0.49, 95% CI 0.39 to 0.62; year 2010: OR=0.79, 95% CI 0.66 to 0.95). The model with interaction terms showed that men were more likely than women to be exposed to workplace SHS (OR=2.02, 95% CI 1.80 to 2.27) but were less likely to be exposed to home SHS (OR=0.79, 95% CI 0.73 to 0.86). SHS exposure in homes was significantly related to lower socioeconomic status, but the 2009 smoke-free policy reduced the difference in SHS exposure across education levels. CONCLUSIONS: The 2009 smoke-free policy reduced the SHS exposure for non-smokers. However, this impact on home SHS did not persist after 2009, and the effect of protection was unequal across gender and SES groups. Thus, further enforcement of smoking restrictions would be needed to reduce the risk of SHS exposure and improve protection against SHS risk among parts of the population with lower socioeconomic status.

Impact of Smoking on Nutrition and the Food Poverty Level in Tanzania.

This study considers the effect of household cigarette expenditure on food poverty indicators in Tanzania. We first compare expenditure patterns as well as the household size of non-smokers and smokers. We find that the majority of non-smokers and smokers have low incomes, and that the mean total per capita expenditure (proxy for income) of non-smokers is slightly higher than those of smokers. On the other hand, the mean household size of non-smokers was smaller compared to that of smokers suggesting that smokers should have spent more on food. Next, we estimate and compare daily calorie intake between both groups. Almost 19 percent of non-smokers were found to be below the poverty line. The corresponding value for smokers was almost 24 percent. Estimates from a multiple linear regression on the determinants of per capita daily calorie intake reveal that per capita cigarette consumption appears to negatively affect daily calorie intake significantly. Given that the majority of all respondents belong to a low income group, this suggests that expenditure on cigarettes may be at the expense of calorie intake.

Impact of Smoking on Food Expenditure among Tanzanian Households.

This study considers the effect of household tobacco expenditure on food consumption in Tanzania. The study hypothesizes that the majority of Tanzanians belong to a low-income group and that any expenditure on cigarettes or tobacco is at the expense of basic necessities, especially food. To verify this hypothesis, we first compared various expenditure patterns as well as household size of nonsmokers and smokers. The results showed that the majority of nonsmokers and smokers belong to a low-income group and that the mean total per capita expenditure (proxy for income) of nonsmokers is slightly higher than that of smokers. Similar results were observed for per capita food expenditure. On the other hand, the mean household size of nonsmokers was smaller than that of smokers suggesting that smokers should have spent more on food. The per capita tobacco expenditure among smokers was 7.73 percent of per capita food expenditure. We estimated a multiple linear regression on the determinants of per capita food expenditure. For each cigarette consumed, per capita food expenditure would decrease by 67.7 Tanzanian shillings (0.08 US dollars). People who smoke and belong to a high-income group (interaction effect) tend to continue to spend less on food. People who are less educated, who are rural dwellers, and people with a large household size, that is, poor people, tend to spend less on food. Given that the majority of all respondents are classified as low-income (more than 54 percent of total expenditure spent on food), one might conclude that expenditure on tobacco in Tanzania is at the expense of basic needs, especially food.

The Demand for Cigarettes in Tanzania and Implications for Tobacco Taxation Policy.

The study attempts to estimate the demand for cigarettes in Tanzania and presents simulation results on the effect of the cigarette excise tax on smoking participation, government revenue, and related topics. After briefly summarizing the magnitude and spread of cigarette consumption in the country, the paper reviews some empirical estimates from African and other countries. The 2008 Tanzanian household budget survey was used to estimate the demand for cigarettes in Tanzania. The descriptive statistics suggest that the smoking prevalence for Tanzania is 15.35 percent with low variability across expenditure (income) groups. Smoking intensity and per capita consumption were estimated at 7.08 cigarettes and 1.33 cigarettes, respectively, a relatively low value. A two-part demand equation model was used to estimate various elasticities. For the overall equation, the price elasticities of smoking participation, smoking intensity, and total elasticity were estimated at -0.879, -0.853, and -1.732, respectively. Compared to similar results in other developing countries, the estimates appear quite high. When estimated by expenditure (income) groups, the magnitude of the elasticity appears higher among high expenditure groups than among low expenditure groups. Two simulation exercises were undertaken. First, the effect of different excise rates on smoking participation rate, cigarette consumption, tax revenue, and related responses was estimated and highlighted. Second, the same exercise was undertaken to determine the effect of a given increase in the cigarette excise tax on various expenditure groups. The overall results suggest that an increase in the excise tax on cigarettes in Tanzania would reduce cigarette consumption and increase government tax revenue.

Healthcare Cost of Smoking Induced Cardiovascular Disease in Tanzania.

The study presented here estimates the total health care cost attributable to smoking induced cardiovascular disease in Tanzania. The study based on a survey conducted at a referral university hospital in Dar es Salaam in 2014. Assuming a 2% prevalence rate of cardiovascular disease and a population of 47.2 million, it was estimated that there are 943,800 cardiovascular patients in Tanzania. The proportion of ever smokers among the surveyed patients was found to be 25 percent yielding 240,400 patients who suffer from smoking induced cardiovascular diseases. Per capita annual expenditure per patient is estimated to be 566.6 US dollars and total annual expenditure for the country was estimated to be 136.1 million US dollars. On a per capita basis more direct and indirect cost is incurred on males compared to females; more is spent on the elderly (40 or more years) compared to the youth (less than 20 years). When compared with the mean annual household income of the surveyed population, the smoking induced per capita expenditure constitutes 35% of household income.

The potential effects of tobacco control in China: projections from the China SimSmoke simulation model.

OBJECTIVE: To use a computer simulation model to project the potential impact in China of tobacco control measures on smoking, as recommended by the World Health Organization Framework Convention on Tobacco Control (FCTC), being fully implemented. DESIGN: Modelling study. SETTING: China. POPULATION: Males and females aged 15-74 years. INTERVENTION: Incremental impact of more complete implementation of WHO FCTC policies simulated using SimSmoke, a Markov computer simulation model of tobacco smoking prevalence, smoking attributable deaths, and the impact of tobacco control policies. Data on China's adult population, current and former smoking prevalence, initiation and cessation rates, and past policy levels were entered into SimSmoke in order to predict past smoking rates and to project future status quo rates. The model was validated by comparing predicted smoking prevalence with smoking prevalence measured in tobacco surveys from 1996-2010. MAIN OUTCOME MEASURES: Projected future smoking prevalence and smoking attributable deaths from 2013-50. RESULTS: Status quo tobacco policy simulations projected a decline in smoking prevalence from 51.3% in 2015 to 46.5% by 2050 in males and from 2.1% to 1.3% in females. Of the individual FCTC recommended tobacco control policies, increasing the tobacco excise tax to 75% of the retail price was projected to be the most effective, incrementally reducing current smoking compared with the status quo by 12.9% by 2050. Complete and simultaneous implementation of all FCTC policies was projected to incrementally reduce smoking by about 40% relative to the 2050 status quo levels and to prevent approximately 12.8 million smoking attributable deaths and 154 million life years lost by 2050. CONCLUSIONS: Complete implementation of WHO FCTC recommended policies would prevent more than 12.8 million smoking attributable deaths in China by 2050. Implementation of FCTC policies would alleviate a substantial portion of the tobacco related health burden that threatens to slow China's extraordinary gains in life expectancy and prosperity.

The effect of cigarette prices on brand-switching in China: a longitudinal analysis of data from the ITC China Survey.

BACKGROUND: Recent studies have found that Chinese smokers are relatively unresponsive to cigarette prices. As the Chinese government contemplates higher tobacco taxes, it is important to understand the reasons for this low response. One possible explanation is that smokers buffer themselves from rising cigarette prices by switching to cheaper cigarette brands. OBJECTIVE: This study examines how cigarette prices influence consumers' choices of cigarette brands in China. METHODS: This study uses panel data from the first three waves of the International Tobacco Control China Survey, drawn from six large cities in China and collected between 2006 and 2009. The study sample includes 3477 smokers who are present in at least two waves (8552 person-years). Cigarette brands are sorted by price into four tiers, using excise tax categories to determine the cut-off for each tier. The analysis relies on a conditional logit model to identify the relationship between price and brand choice. FINDINGS: Overall, 38% of smokers switched price tiers from one wave to the next. A ¥1 change in the price of cigarettes alters the tier choice of 4-7% of smokers. Restricting the sample to those who chose each given tier at baseline, a ¥1 increase in price in a given tier would decrease the share choosing that tier by 4% for Tier 1 and 1-2% for Tiers 2 and 3. CONCLUSIONS: China's large price spread across cigarette brands appears to alter the brand selection of some consumers, especially smokers of cheaper brands. Tobacco pricing and tax policy can influence consumers' incentives to switch brands. In particular, whereas ad valorem taxes in a tiered pricing system like China's encourage trading down, specific excise taxes discourage the practice.

WHO Framework Convention on Tobacco Control in China: barriers, challenges and recommendations.

AIM: The aim of this study was to analyze the barriers in the implementation of the Framework Convention on Tobacco Control (FCTC) in China and present recommendations on ways to address these challenges in tobacco control in China. METHODS: We review the available literature on progress and explore the barriers and challenges that impede a speedier pace in the adoption of the effective tobacco control measures, and present recommendations based on in-depth knowledge of decision-making process on the implementation of FCTC in China. RESULTS: The pace of progress in China is too slow. China faces intractable political, structural, economic and social barriers in tobacco control, which make the whole-hearted implementation of FCTC measures a painstaking process. DISCUSSION: The authors recommend a comprehensive approach to speed up the implementation of tobacco control measures. This includes strong political leadership from the top, structural changes to the tobacco industry and government oversight of the tobacco industry, as well as advocacy and support for tobacco control from civil society at the grassroots level.

Can increases in the cigarette tax rate be linked to cigarette retail prices? Solving mysteries related to the cigarette pricing mechanism in China.

OBJECTIVE: To explain China's cigarette pricing mechanism and the role of the Chinese State Tobacco Monopoly Administration (STMA) on cigarette pricing and taxation. METHODS: Published government tobacco tax documentation and statistics published by the Chinese STMA are used to analyse the interrelations among industry profits, taxes and retail price of cigarettes in China. RESULTS: The 2009 excise tax increase on cigarettes in China has not translated into higher retail prices because the Chinese STMA used its policy authority to ensure that retail cigarette prices did not change. The government tax increase is being collected at both the producer and wholesale levels. As a result, the 2009 excise tax increase in China has resulted in higher tax revenue for the government and lower profits for the tobacco industry, with no increase in the retail price of cigarettes for consumers. CONCLUSIONS: Numerous studies have found that taxation is one of the most effective policy instruments for tobacco control. However, these findings come from countries that have market economies where market forces determine prices and influence how cigarette taxes are passed to the consumers in retail prices. China's tobacco industry is not a market economy; therefore, non-market forces and the current Chinese tobacco monopoly system determine cigarette prices. The result is that tax increases do not necessarily get passed on to the retail price.

Secondhand smoke exposure at home in rural China.

PURPOSE: This study estimated secondhand smoke (SHS) exposure at home among nonsmoking children (age 0-18) and adults (age ≥ 19) in rural China, and examined associated socio-demographic factors. METHODS: A total of 5,442 nonsmokers (including 1,456 children and 3,986 adults) living in six rural areas in China were interviewed in person. The standardized questionnaire obtained information on their demographic characteristics and SHS exposure at home. Differences in SHS exposure were assessed by use of the chi-squared test. Logistic regression analysis was used to examine the associated factors. RESULTS: Occurrence of SHS exposure at home among nonsmoking children and adults was 68.0 and 59.3%, respectively. Logistic regression analysis found that children living in households with married, low-education, and low-income heads of household, and those who resided in the Qinghai province of China were more likely to be exposed to SHS. Among adults, those who were female, aged 19-34, single, low-education, and low-income, and those who lived in Qinghai province were more likely to be exposed to SHS at home. CONCLUSIONS: Our findings of substantial SHS exposure at home in rural China emphasize the importance of implementing interventions to reduce SHS exposure among this population.

Capitation of public mental health services in Colorado: a five-year follow-up of system-level effects.

OBJECTIVE: Capitated Medicaid mental health programs have reduced costs over the short term by lowering the utilization of high-cost inpatient services. This study examined the five-year effects of capitated financing in community mental health centers (CMHCs) by comparing not-for-profit with for-profit programs. METHODS: Data were from the Medicaid billing system in Colorado for the precapitation year (1994) and a shadow billing system for the postcapitation years (1995-1999). In a panel design, a random-effect approach estimated the impact of two financing systems on service utilization and cost while adjusting for all the covariates. RESULTS: Consistent with predictions, in both the for-profit and the not-for-profit CMHCs, relative to the precapitation year, there were significant reductions in each postcapitation year in high-cost treatments (inpatient treatment) for all but one comparison (not-for-profit CMHCs in 1999). Also consistent with predictions, the for-profit programs realized significant reductions in cost per user for both outpatient services and total services. In the not-for-profit programs, there were no significant changes in cost per user for total services; a significant reduction in cost per user for outpatient services was found only in the first two years, 1995 and 1996). CONCLUSIONS: The evidence suggests that different strategies were used by the not-for-profit and for-profit programs to control expenditures and utilization and that the for-profit programs were more successful in reducing cost per user.

Economic costs attributable to smoking in China: update and an 8-year comparison, 2000-2008.

OBJECTIVE: To estimate the health-related economic costs attributable to smoking in China for persons aged 35 and older in 2003 and in 2008 and to compare these costs with the respective results from 2000. METHODS: A prevalence-based, disease-specific approach was used to estimate smoking-attributable direct and indirect economic costs. The primary data source was the 2003 and 2008 China National Health Services Survey, which contains individual participant's smoking status, healthcare use and expenditures. RESULTS: The total economic cost of smoking in China amounted to $17.1 billion in 2003 and $28.9 billion in 2008 (both measured in 2008 constant US$). Direct smoking-attributable healthcare costs in 2003 and 2008 were $4.2 billion and $6.2 billion, respectively. Indirect economic costs in 2003 and 2008 were $12.9 billion and $22.7 billion, respectively. Compared to 2000, the direct costs of smoking rose by 72% in 2003 and 154% in 2008, while the indirect costs of smoking rose by 170% in 2003 and 376% in 2008. CONCLUSIONS: The economic burden of cigarette smoking has increased substantially in China during the past decade and is expected to continue to increase as the national economy and the price of healthcare services grow. Stronger intervention measures against smoking should be taken without delay to reduce the health and financial losses caused by smoking.